Minutes from LSA Meeting 28th November 2018
‘End of Life Care?’
Drs Lawrence McCrossan, Royal Liverpool University Hospital.
LSA President, Dr Ed Djabatey, opened the meeting and introduced the speaker, Dr Lawrence McCrossan. Dr McCrossan introduced his talk with an ethical dilemma that he had faced. A delirious patient had been admitted to ICU and whose level of care had then escalated without improvement to the point of considering the withdrawal of care. The patient’s family disagreed with this view and sought their own second opinions from other hospitals who could offer few additional treatment suggestions. A complex situation arose between the ICU department and the family when the patient didn’t die as expected when treatment was withdrawn. Consequently, the family went on to do extensive research, demanding treatments that were inappropriate and out of date. It became a very difficult situation where the ICU consultants were starting to be viewed as weak, being pushed around by the family. The ICU consultants sought their own second opinion from a consultant at Whiston who spent a long time considering the case, so much so there was not much to withdraw when he was giving his final opinion. Legal teams became involved and care was escalated once again. This made him think that there must be a better way to do this? He said this case made him very interested in the end of life aspect of intensive care. He became involved in the palliative care aspect and was asked to be on the clinical ethics committee due to his experience. He became more interested in communication and conflict and undertook a mediation course. He was then asked to sit on a RCoA discussion panel on end of life issues for their 25th anniversary meeting which led to him writing the article in the BJA with Rhona Das.
Dr McCrossan described the article which was based on a question from a colleague, ‘what should you do at 2am when you meet with a patient or their family who want you to do everything despite you knowing it probably is not the right thing to do?’ He thought this to be very difficult especially if the family are hostile. He wrote the BJA article as he felt there had been a shift from medical paternalism to meeting patient/family demands whatever they may be. That may feel uncomfortable and wrong but he thought that we must have a moral imperative to act in the best interests of the patient. He described the professional and ethical guidance from the GMC, BMA on end of life issues and withdrawing treatment which is not uniform and varies.
Dr McCrossan spoke about the term ‘futility’, its different definitions and how published guidance states that it should only be used in certain circumstances. The term, ‘potentially inappropriate’ should be used instead. He said despite this, the word is used frequently and has been described as a subjective term masquerading as an objective one. He said if the word was used, it should be justified. He described his favourite definition of it in Wilfred Owen’s poem.
Dr McCrossan went on to describe the term, ‘best interests’ and its use in the mental capacity act and various descriptions from legal cases. He said it’s difficult because the patient’s wishes are not always in their ‘best interests’. He described the term ‘justice’ and being fair and reasonable. He spoke about controversial articles written by Prof Julian Savulescue and Dominic Wilkinson describing the 3 ethical principles which needed to be abided by in a publically funded health system. These are: treatments to be decided on basis of ‘distributive justice’, treatment provided in the patient’s best interests and a competent patient either consents to treatment or declines treatment. But, he said if there are insufficient resources, then it’s ethical for doctors to decline treatments considered to be medically inappropriate or futile where there are not sufficient resources.
Dr McCrossan talked in detail about 4 court cases which contributed to the GMC guidance. He also discussed a further example of a clinical case, where mistakes in care prior to referral to ICU had left a family feeling very angry and untrusting of doctors. After listening to their background story, he was able to have a conversation regarding management.
Finally Dr McCrossan thought that we should not be facing these scenarios at 2am. We need to relook at death and dying, recognising better when end of life is near. He said that we have a death denying culture but we should talk to patients about prognosis early on and give patients and families the right information. We should talk about function and frailty rather than survival which may mean having difficult conversations. He said that he speaks more frankly to patients face to face about dying and death and encouraged everyone to do this more.
Dr McCrossan took questions from the floor and Dr Nicole Robin gave the vote of thanks.
LSA Honorary Secretary December 2018